BreatheTV Episode 22

Transcription

Jeanne Pettinichi: Welcome to the Vapotherm Roundtable Discussion today. My name is Jeanne Pettinichi, I am the Clinical Nurse Educator in the medical education division, here at Vapotherm. I’ve been a nurse for 30 years. I have primarily experience in the pediatric emergency department and my experience with Hi-VNI Technology is in the Peds ED. I would like to introduce our guests: Rose Dennis and Dianna Maynard who are respiratory therapists and authors of a recently published randomized clinical trial “High Velocity Nasal Insufflation in the Treatment of Respiratory Failure.” So it’s a pleasure to have an opportunity to discuss your experience as participants in this study and as well as your clinical experience using Hi-VNI Technology.

So welcome, Rose. Can you please give us a little bit of a background on your experience.

Rose Dennis: Hi, I am Rose and I have 34 years of experience in respiratory care and 21 years of experience in nursing. I’ve done therapy and nursing in almost every arena. I’ve worked with high flow therapy in the neonatal population at the beginning of high flow and I’m pretty much using high flow in all areas right now: pediatric, adults and the E.R. And we’ve very happy to be part of this successful study.

Dianna Maynard: Thank you for the opportunity to be here. My name is Dianna Maynard. I’ve worked in respiratory for almost 20 years. Like Rose and her institution, we’ve been using high flow therapy for several years now. I’ve had the opportunity to work with it in the NICU, in pediatrics and in the adult populations. I’ve used in in a rehab hospital, acute care hospital and critical care, in the ED, and so I would say I have quite a bit of experience using High Flow Therapy, or Hi-VNI in all setting and all age populations.

JP: Thank you and welcome. We certainly have a lot of experience and expertise today for this discussion. So you see Hi-VNI as an easy tool to set up and manage for the patient and increased comfort?

DM: And time-efficient.

JP: So a question I frequently get from around the country from clinicians is how to titrate flows. So tell me what are the current protocols in your hospital for titrating flows for the adult patient in respiratory distress, what do you recommend [as] starting flows?

RD: We recommend starting flows fairly high if you have a patient in respiratory distress. So meet that patient’s respiratory demand or exceed that patient’s respiratory demand. We’re gonna start high. Usually about 25 to 35 on the flows and if you got a patient who’s really crashing, we might go straight to 40 and if we need to titrate down, we will, but you know, you want to quickly meet that patient’s demand.

RD: We start at 100% here on chronic lung patients, COPD patients, we may not start at 100%, but it just depends. Again, everything is … I always tell my therapists to evaluate the patient and your therapy is patient dependent, but routinely we start high on the flows, high on the FiO2, and with the COPD patient we are concerned about the patient’s drive to breathe and we’ll come down the FiO2 a little quicker because normally our protocol is to maintain a saturation of 92% so we wean them down too depending on that saturation of 92%. So we wean FiO2s first and then wean flows later.

DM: And I have to echo that at our facility we manage it the same way. if they come into the ED in respiratory distress we’re gonna start at a high flow to meet their demand and most of them are hypoxic and we see that when they initially present with their O2 saturation so we set the FiO2, usually it’s high, we need it high and we titrate quickly down, as quick as we can to maintain sat at our facility, 92% or better. If it’s a known COPDer with CO2 and they’re a CO2 retainer, we will titrate to keep sats 88-92%. We do wean the FiO2 first and we wean that as quickly as we can before we begin to wean the flow.

JP: So it sounds like you both start high with your flows and your FiO2 and you wean it down, titrate based on your patient’s response. So, how does that differ from your initiation of NIPPV therapy for a similar patient.

DM: Well, on NIPPV, at our facility, the way we practice, we usually start at lower level pressures, an inspiratory pressure of 10, expiratory pressure of 5 then we titrate up to meet the patient’s needs, so it’s opposite of Hi-VNI. So you’re trying to catch up with the patient’s needs, you don’t start with the high pressure. it’s very hard for them to tolerate that pressure at all, so you can’t start at a high pressure. I would say 95% of the cases, they would rip the mask off.

DM: I believe it does. I think that’s why we see a quicker response with Hi-VNI because you meet their demand quicker, initially rather than titrating up like you do with noninvasive ventilation.

JP: Can you also share any recommendations for specific flow and FiO2 weaning protocols?

DM: We, when they present we start them off at either 30-35, FiO2 usually at 100%. Again, we wean the FiO2 to keep the sats greater than 92% or if they’re a known COPD patient with CO2 retention, we wean to keep sats 88-92% and we do wean the FiO2 first. Our goal is to get below 60% to prevent O2 toxicity and then we would wean the flow, we’d titrate up if we weren’t meeting their demand, we’d go all the way up to 40 and you know that by looking at the patient, by measuring the respiratory indexes, their heart rate, respiratory rate, O2 sat, looking at your patient, work of breathing is probably the biggest indicator for me. And if you do get an appropriate therapeutic response then you’re gonna maintain that flow until the patient starts to get better. We titrate down between 5-10 on the flow and as long as we’re able to meet the patient’s demand and work of breathing doesn’t start increasing, heart rate doesn’t increase, respiratory rate doesn’t increase and then we continue to bring the flow down.

RD: We got guidelines for the FiO2 as well where, you know, if there are different steps or increments, in weaning the FiO2, but also, as Dianna said you’re gonna look at the patient response. So if your sats are hanging really high then you can bring the FiO2 down a little quicker, but if it’s staying around 92-93, then you might do a 0.1, you know increments, slowly bringing the FiO2 down. But we would bring the FiO2 down quicker in patients than the flow.

DM: I think as you get the CO2 washout effect and you start bringing the CO2 levels down, you’re able to wean the FiO2 down quicker. You no longer have anatomical dead space … it’s all oxygen enriched, your upper airway so you can bring that FiO2 down quicker as long as your flow is appropriate.

JP: So always looking at your patient and really using as your evaluation tool to determine your weaning. So, optimizing patient throughput through the ED and critical. Do you have protocols in your hospital for determining disposition for patients on the two different therapies. Is there any difference in the dispositions?

RD: At our institution, if a patient is stable, hemodynamically stable, not requiring any drugs that we can’t give on the general floors, those patients can be discharged to the floors and I would say any of our floors, we can put High Flow patients. We have Vapotherm on the floors all the time. We wouldn’t have enough ICU beds, really. So if we do have a patient that’s pretty unstable, we do have a step down area so you would see a number of our noninvasive ventilation patients there as well as our high flow patients, but our patients can go anywhere on our floors.

DM: It’s very similar at our institution as well. I think the more critical the patient is, if you have a patient that we haven’t stabilized yet, they’re going to get to the critical care unit. I think the patient stabilizes better with Hi-VNI. That’s why we’re able to put them in a step down unit or even on the general medical floors. With noninvasive ventilation again it’s that compliance issue. The patient wants to come off, the nurse may take them off. The patient becomes dyspnic, the work of breathing goes up so you put them back on noninvasive therapy, so they seem to remain in the ICUs longer because of that reason. We don’t haev that problem because you don’t have to take the Hi-VNI off the patient like you do with noninvasive. Wouldn’t you agree?

RD: Oh, I agree.

DM: It comes down to that.

RD: They’re unstable and in the ICU and if they’re patients who were extubated, but didn’t tolerate the extubation, we put them on high flow. They may stay in the ICU for a while, but as soon as we get them stable, we’re constantly moving patients just to get them out of the ICU.

DM: And the nurses are much more comfortable in our stepdown unit, we do have noninvasive, but they’re so much more comfortable receiving a patient on Hi-VNI as opposed to a patient on noninvasive ventilation. That seems a little intimidating to them.

JP: You see the utilization of Hi-VNI as a means to keep your patients out of the ICU?

RD: Yes.

DM: Yes.

JP: What are some of the patient parameters that guide your clinical recommendations for use of either Hi-VNI therapy or NIPPV?

RD: I would say over the last 15 years, we have been using high flow. From the 2000i in the NICU and we didn’t have the opportunity of using it in adult care. So now we use it in pediatrics, we use it in adult care and we were not using it in the ED so when those patients presented in the ED, we would go right to noninvasive ventilation with masks and to try to prevent intubation. So now I feel we’ve come full circle because we can use it in every entity of our hospital now. So that’s been a plus for us and there hasn’t been really … therapists have gotten used to it now and our physicians are pretty much on board, unless somebody is new coming through the door, we don’t have to say “are you okay with me doing this?”

DM: Same experience for me and in our facility. Prior to the study, we didn’t use high flow in the ED at all. I mean it wasn’t an option. It wasn’t a tool in our tool chest, we used it in the critical care areas, we used it in the NICU we used it in pediatrics, but we just didn’t use it in the ED. I’m not sure why we didn’t ever think to use it in the ED, but we didn’t and as a result of the trial, I mean, Hi-VNI is the go to for a patient that walks through in respiratory distress. We’re gonna try that before we try noninvasive.

DM: So adults if they come in in respiratory distress that’s what we’re gonna put them on in our facility. Pediatrics, it’s great for bronchiolitis, because it helps with secretion mobilization, it humidifies the secretions so you get good clearance of the secretions. So we use it in pediatrics for bronchiolitis. We use it in our rehab hospital as well for secretions to humidify the upper, uh, the lower airway for pulmonary toiletry, so not just for respiratory distress, but for pulmonary toiletry as well. And of course for respiratory issues, distress, work of breathing in the NICU, we use it.

RD: I think we just didn’t see it as an emergency intervention in the ED. But now when you go into our ED, you got the ventilator sitting, we have the Vapotherm sitting we have two BiPAPs sitting …

DM: And it’s because we did not understand or know that we could use Hi-VNI for hypercapnic failure. We didn’t know we could increase CO2 elimination by washing out dead space. We knew that, we knew if you wash out the dead space you would get minimal CO2 … a minimal decrease in your CO2 levels, but it was just not minimal, it was just as effective as noninvasive ventilation in bringing down CO2 levels and we didn’t know that prior to the study so patients that come in in respiratory distress, the majority of them in the ED are gonna have pr gonna be hypercapnic, not just hypoxemic, so it just never clicked to use Hi-VNI because we didn’t now. We didn’t understand the technology first of all and we didn’t now what Hi-VNI was capable of.

RD: And then in the ICU we’re using it, but in patients they were hypoxemic, the respiratory rates were up, they were working hard and it would meet that need, but we just didn’t think about it.

DM: And again, if they were hypercapnic we automatically went with noninvasive, we didn’t even think this because Hi-VNI or high flow therapy was for hypoxemic failure.

JP: So you definitely see it as an effective alternative to NIPPV. Can you share a clinical situation where you recommended Hi-VNI instead of NIPPV?

DM: I would recommend it and I think it should be the go-to therapy that present with respiratory distress, if they’re dyspnic and if respiratory failure. Noninvasive ventilation is an option, but I think in those cases we should start with Hi-VNI. The patients will tolerate it better. They can still speak to you, they can still eat if they, you know as they get better and need to eat, they can still take things in orally. You don’t have to troubleshoot Hi-VNI like noninvasive and it is an effective therapy for CO2 elimination.

RD: And I just have one last week, I was just thinking, but I had one patient last week, heard the therapist in the hall talking about this patient struggling and the patient wasn’t tolerating the mask with the noninvasive ventilation so I said, “did you try Hi Flow, did you try Vapotherm?” And so that therapist went back to the bedside and actually put that patient on high flow with Vapotherm and the patient did fine with it. So I mean, we get those all the time, sometimes you just don’t think about it.

DM: And it is so common that you don’t think about it.

RD: Right.

JP: It sounds like you do have some autonomy to be able to advocate for your patient and really know what’s the best therapy.

RD: Yes, we do have. I think that alternative is now is like … Before if you were just trying to prevent the intubation, but the patient just didn’t tolerate the mask, or noninvasive ventilation, because again, leak compensation the pressure, that air in their face, claustrophobia, high risk for aspiration then we didn’t have an alternative, but now we do. So, again the therapist, they are really used to thinking about it now so when you get together as a group and brainstorm together, just try that [Vapotherm] see if it works.

DM: And it’s really exciting for me to be a part of and watch the journey of Hi-VNI from when it was first presented, when we first started using it it was an option for hypoxemia and then as we learned that we could use it in the treatment of hypercapnia, to see the physicians, not just the ED physicians, but the hospitalist and pulmonary physicians slowly begin to use it to now where we are, we use Hi-VNI before we’ll use NIV. It’s been neat to watch the transition over the last couple of years. To watch them begin believing in it.

RD: Yeah, one other example: we see in the hospital because we have a hospice and we would have patients on high flow and trying to get that patient off of high flow onto the hospice floor, never saw it happen, it rarely happens, so usually when that patients moves from the general floor or palliative care to hospice the Vapotherm goes with them and because the patient or patient family still wants it, we pretty much leave it as patient comfort, they can have it, until that time comes and then we’ll take it. We see it in that population of patient a lot.

DM: We have patients you know in the COPD population you have the frequent fliers, you know, they come in often and we all the therapists and the nurses all know those patients, they’re like family, sop we’d have one of our frequent fliers come in through the ED and be randomized to Hi-VNI and they liked it so much that the next time they came in they specifically asked for “remember that thing you put on me last time? The cannula? I want that. Don’t put me back on that mask. I mean, we literally had people request it, COPDers requesting Hi-VNI when they came into the ED.JP: Sounds like a big patient satisfier.

RD & DM: Oh yeah.

JP: Although our focus as clinicians lies with the clinical benefit and the patient outcomes, similar to what you’ve been describing, the economic impact of the therapy and interventions–we can’t overlook that component as well. How does Hi-VNI impact the economics in your department?

RD: What I see, I think it impacts length of stay. I think it helps reduce stay in the ICU, stay in our ER as well. Sometimes getting patients stable quicker, a few that can discharge from the ED will go up to our ops floor, but certainly patients feel more comfortable on it and go the general floors a little bit quicker because of it and don’t take up an ICU bed.

DM: I agree and in addition to that, just the time involved in administering and troubleshooting and adjusting the therapy for the clinician, there’s much less time involved. I think you save money there as well. The therapists can go do other things.

RD: So, on the front end, it may cost more in consumables, but we think cost avoidance and a decrease of expenses when it comes to labor and for the nurses as well as the therapists, the time that it takes to care for these patients. If you’ve got a therapist who is called 4, 5, or six times “can you take this patient off so that they can eat, off of the mask, can you take the patient off so that they can go to the bathroom, so that they can take medication,” so there’s a lot less of that right now. So, the therapists, I tell you, they can tell that story that it’s so much easier to manage a patient with a cannula on versus a mask.

JP: So a lot less interruption for the clinician.

RD: Especially those unstable patients, just at night sleeping who knows how to manage their machine? Not a problem. But those critical patients you are trying to get stable, they can require a lot of the therapists and nurse time. More than the ventilator patients.

DM: Absolutely.

JP Sounds like a positive because it really impacts productivity for your departments as well. Can you talk about what was important to your team in terms of clinical protocols and training to successfully integrate a new technology like Hi-VNI into daily use?

RD: Well, what we saw was, we started getting everyone on board. That’s our therapists, our physicians, our medical director the nurses, just informing and educating everybody on what we’re doing and making sure they understood the therapy and then actually seeing the results, I think made the difference.

DM: Yeah, seeing the results made a difference. I think the educational foundation is very important. I think it’s very important that the clinicians, from the physician to the respiratory therapist that they understand the technology. I think there’s probably misconception about how it works. I think resistance some facilities may have in using Hi-VNI Therapy that is specific to Vapotherm, the resistance they may experience with their physicians I think it’s due to a lack of knowledge of how the technology works. Because again, it’s not just high flow therapy. It’s high velocity therapy that is able to do such an effective job of washing out the dead space.

RD: And what we offered our staff as well is support. I mean 24/7. So as we were doing the study, if they had questions they could call. We had somebody on call they can call, even if the person didn’t come in. So I think that’s why we were pretty successful with our study. Made sure everything was done the same way because we had that support and we had the calls readily available.

DM: And then as you said Rose, as soon as the clinicians saw the results, it didn’t take long at all. As soon as they saw the results, they bought in. It was exciting. As a respiratory therapist at our facility, we had the privilege of autonomy. I know at many facilities, the respiratory therapists don’t or they have very little, but at our facility we do and I think this allowed us to have even more autonomy in the treatment of patients. When we go to the physician, we talk to him and we recommend therapy that he may reluctantly let us try and then he sees that it works. It gives us credit as to what we’re doing and what we know. And I think that Hi-VNI therapy has provided us with even more justification for autonomy in our facility.

RD: A big thing for us initially getting the physicians aware of what we wanted to do in the ED with high flow. They didn’t realize we had Vapotherm throughout the house for some reason and we were treating patients and having success with these patient outcomes so in the ED once we sort of got that information to them: this is not new technology for us, we’ve been doing this 15 years, our patients are safe–because we had some doctors who thought we were bringing new therapy in the house and thought respiratory wouldn’t know what to do with it. We knew what to do with it. So, once they realized that, again we were put in the driver’s seat. And normally that’s what they let us do. We have protocols and we do drive the car and we see these patients, put them on what we thought would work and again we know we have choices too, We have them to consult with and we do have other choices so if high flow doesn’t work we could try noninvasive ventilation as well so it’s not like, you know, just one therapy that we would have. But again, it worked very well for us because we had the knowledge and experience already and the doctors really trusted what we were doing with the therapy.

DM: And it fits for us at our facility, it fits perfectly with our protocols. It really does. Because we did have an oxygen pathway or protocol and it just fits right in with that one. We don’t have to call to get an order of Vapotherm for high flow therapy. It works in our ventilation protocols, it’s an option for our secretion mobilization protocols, so it just fit right in seamlessly.

JP: So having those evidence based protocols really supports the autonomy of the RTs and really makes a difference in that for the clinical decision maker.

DM: And it allows us to practice to our potential and actually assists the physician, so free him up so he has time to focus on other patients.

RD: We just get parameters and pretty much up and down how we need to take care of the patient.

JP: What were the assessment parameters you used to guide your clinical decision making in moving a patient from Hi-VNI Technology or NIPPV to a higher level of care?

DM: Well, we look at a patient’s response. So, their work of breathing. We can tell fairly quickly whether or not we’re relieving the patient’s work of breathing just by looking at them. So are they still using their accessory muscles, is their heart rate still climbing, is their respiratory rate still climbing? We assess whether or not there is an appropriate response by those respiratory indexes and also we can see if the patient is not responding, if the therapy is failing by those indexes. Usually you know, we don’t have a time parameter. We don’t necessarily say “every 15 minutes”. When those patients come in in respiratory distress we place them on the therapy of choice whether we’ve chosen Hi-VNI or noninvasive ventilation, but you should start seeing a therapeutic response fairly quick. In either case, a lot of times in noninvasive the patients fight, they’re not compliant they’re not able to be and you know it’s not gonna work. Traditionally those were the patients where we would just go ahead and intubate, but we don’t just rely on blood gasses to see if it’s working. I mean you tell a lot about whether or not the therapy is working by the patient’s work of breathing.

RD: Yeah, to what Dianna said, we look at altered mental status, patients becoming unresponsive for some reason then those patients we would certainly take off of high flow or noninvasive ventilation and intubate.

DM: Yes, I agree. So they become … if their respiratory depression is increasing, then you would escalate the therapy.

JP: Getting the spontaneous respirations.

RD: It’s hard to give you a time. If we’re seeing improvements in respiratory rate and in sats, you know sats may sometimes take a little bit longer, but you know it’s a holistic thing. That’s why you have to really look at the patients.

RD: Like with arrhythmia or something that we think is life threatening, then we’re going to make a move very quickly.

JP: So you definitely want to see that response in the heart rate, respiratory rate, work of breathing and your blood gas improvement?

DM & RD: Yes.

JP: As you were implementing the technology with the Hi-VNI Therapy, what were some of the challenges that you faced during that implementation?

DM: I think some of the challenges was understanding the technology. So some of the things that we did see … one of the things that we saw was that the physician would order the therapy with flows that were too low. You have to meet the patient’s inspiratory demand and they would oirder a flow of 10, a flow of 15, which, for a patient in respiratory distress, their demand is greater than 20 usually, and adult patient anyways. So, ordering the flows too low, we’ve experienced that a few times, but the education, that’s how you address that. With the education. I think another problem that another challenge that we have is the bulkiness during transport. I know Vapotherm has come out with a lighter battery, but we haven’t purchased one yet and we’re budgeting one for next year, but I think the heaviness of the unit during transport has been a challenge and to make sure your therapist doesn’t switch the patient to a nonrebreather for transport, that we keep them at the same level of care, with the same therapy for that transport even though it might be a little bit slower, and so that’s kind of been an obstacle.

RD: What we saw, was probably mainly physician driven in the ED, where the physician was still not thinking high velocity therapy, but because they were used to and had seen outcomes with noninvasive ventilation, then we would get physicians just wanting it regardless of what we were telling them. You know, you have certain doctors rotating into your ED so if it wasn’t physicians who were involved with the study we would have then explain again how it works, let us try this and we got a few, when we randomized the patients that would say “no, I think I want noninvasive ventilation anyway” so we really had to show those doctors that the therapy worked and it was just as good, a good tool for us to use. So, that was some of what we saw and then getting all the therapists on board in the ED because we had to change some of their mindset, too and them being the more aggressive person or clinician at the bedside to help teach the nurses, help teach the physicians, so that was some of what we saw and then after we got our therapists not being so shy about it and just to think “well you use this on the floors, it’s not so much different, but you have to meet that patient’s demand and don’t start with the flow so low. Don’t be afraid, you can always titrate down.” So we had to really get the therapists to see that 40 wasn’t bad, 35 wasn’t bad cause they wanted to start low and then go up, they thought more like noninvasive ventilation so we really had to get that switched around. That thought process.

DM: Yeah, I agree.

JP: Different initiation process for the different therapies. So, education was important, make sure that everybody understood the mechanism of action, sounds like the RTs can really drive that understanding to the rest of the clinical team.

RD: And I gave in sometimes with the physician. If they really … if the doctor wants this, so unless one of us came out of the office to talk to the doctor, which we did, they would give in.

JP: And now you’re seeing more autonomy with the therapists?

RD: Oh sure, they’re comfortable with it.

JP: Is there anything specific that you had to really hone in on to get the physicians to understand and believe in the therapy?

RD: Yeah, we had to pretty much let the physicians see the results quickly. Get the results right to the bedside so that the physicians could see. Or they could just come in and see the patients themselves and once they saw it pretty much in action, then the proof was already in the pudding, my patient’s doing better, I think this can work, I see the blood gas, I see the patient’s CO2 is coming down, parameters are looking much better, hemodynamically they’re ok, so I think they’re really pleased.

DM: They bought into it as soon as they saw the results. We did have a few physicians that rotate through. They might not always be in the ED and aren’t aware of the therapy. During the trial we’d go to them, they happened to be the treating physician and they would not want to put the patient on Hi-VNI when they randomized to Hi-VNI, but we had a lot of support from our medical director of the ED, so he would address those issues immediately and educate the physician, so even as a therapist, being part of the clinical trial, you try to educate that physician who just rotated through the ER, but they don’t know who you are, they’re not sure, so sometimes you would struggle, I would struggle in getting that message across. But I could go to my medical director and immediately he would help me diplomatically handle that situation. We had great support.

RD: It got easier as we got more doctors on board because we had a physician champion who was really there.

DM: Which makes a huge difference. And then another challenge, it wasn’t such a big challenge, but it was a challenge, especially initially was our ED physicians were on board with this, they were ordering it, but as the patient transitioned to in-patient, the pulmonary doctor would come by, see the patient’s CO2 level was elevated, although he obviously wasn’t following the multiple blood gasses, but he would just see an elevated CO2 and immediately see that Vapotherm and put them on noninvasive, so making sure we immediately saw we had to get to our pulmonary doctors and educate them or they would be pulling all of our patients out of the study.

RD: We saw the same thing.

DM: But as soon as education was done, and we should have educated them beforehand, we kind of mentioned it, but they have so much going on, when it actually started happening …

RD: They didn’t have the same mindset we did. High flow was useful, you know what I’m saying?

DM: They did, I even had them tell me that initially when we started this. Once you educated them and they began seeing it, they backed off that.

JP: What are your recommendations for a hospital that’s not currently using Hi-VNI Technology in their adult population? How would you recommend that this therapy be implemented?

RD: I would suggest this because over the years of using high velocity therapy, we have been like a resource to hospitals that were hesitant or just didn’t, weren’t sure about the therapy, how it would work, and we don’t mind doing that now if there’s hospitals if they want to send a therapist or want to call us or sort of want to see what we’re doing or how we’re doing it, I think that helps sometimes with those hospitals who are just not sure if they’re doing to get the patient outcomes or are not sure that the therapy works, we could certainly share real cases with them. I think that would help. Those people who are just not sure.

DM: I agree.

RD: I think the evidence is there and …

DM: The evidence is there …

JP: You want to give that validation.

RD: You can give them articles, you can give them sometimes people think, well, you guys did the study, you guys gave us the information, all you gave us was the positive and none of the negatives, but I think if you find a facility that is using your technology and have that person reach out to them.

DM: We don’t have a dog in the fight.

RD: Exactly and so we’re willing to share and I think that might help some of them. They could certainly come visit, put hands on, look at it. see what our patients look like with it on. That’s my suggestion, I don’t know …

DM: I think the proof is in the pudding with Hi-VNI. The evidence is there, they’re just going have to practice evidence-based medicine and they can call for validation.

RD: Yeah, they can call, or again, site visit, you know, I think we all sort of share these days. So that would be good, just like, you know, us going to a new EMR, I’m gonna go look at it so I can get a true feel for it. If you tell me this all day long, I might not really know exactly what it’s gonna be like until I see it. So maybe that is the case with a lot of these hospitals that don’t now how to move it from neonatal or pediatrics into the adult are, but when we had it just in neonatal and pediatrics, we wanted to get it to our adult patients. We kept saying “when are you guys gonna get an adult unit?” We weren’t scared of putting it on an adult because we saw how well it was working for the kids.

JP: Change is always a little bit challenging to bring in new therapies.

DM: But I think in facilities that look to patient safety and outcomes, they have to at least consider it. I can’t imagine them not at least considering it, since the evidence is there. We all claim to be evidence-based institutions.

JP: Well said. Are there patients, specific patients, that you would only use NIPPV instead of Hi-VNI as the preferred therapy?

RD: I would only do that and not evaluate or consider, or high velocity therapy on a patient that comes into the ED and their therapy at home or they prefer noninvasive positive pressure ventilation because that’s what they’re used to, that would be the preference of the patient to me, because that’s what they’re used to and they respond well to it and that’s what they want. On those patients, I would probably just leave that on that therapy because it worked, you know.

JP: So they may not have that mask anxiety.

DM: I really can’t think of a patient where noninvasive would be preferable just because of the interface and the struggle you have getting the patient to relax.

RD: ‘Cause you have some patients who just want what they want. Some COPD patients, they want what they want, so if they’re used to the mask and that’s what they want, and again, those patients sometimes they settle down and they want to come off, but they can’t come off the therapy completely, and maintain their sats, then we’ll put them on high flow as well, so we’ll have high flow and noninvasive ventilation in their room as a dual therapy. When you’re doing this, then that therapy. So, you know, but that’s the only time that I wouldn’t …

DM: I have to agree, that I can’t think of a time.

JP: So no specific situations where a patient …

DM: I mean, the patients are much more compliant, they both produce the same results, so why wouldn’t you use Hi-VNI as opposed to noninvasive. Unless, you know, the patient, a COPDer, somebody headstrong, they know how to treat their disease

RD: And they don’t see that this would work, a cannula’s not gonna work like my mask.

DM: They’re not gonna change.

RD: Just like, you know, a patient who, if you want to give them an MDI treatment for their medication, but they’re used to taking a nebulizer, you can’t prove to them that this is just as good, or probably better, because they’re used to that nebulizer.

JP: So, sometimes patient preference play in. Do you have specific clinical criteria for disposition to ICU for a patient on Hi-VNI or NIPPV?

DM: It depends on the patient. So, the more acute the respiratory distress is, the more needs the patient has, whether or not they’re hemodynamically stable, whether or not they have multiple issues going on, there are several factors that influence that, not just respiratory distress and their response to the therapy you’re giving them. A lot of our patients come in and have multiple co-morbidities and they may be having arrhythmia going on, and so there are multiple factors going on that affect disposition

RD: Their hemodynamic status, their medications because if we got somebody on pressors or inotropes like cardiac drugs, they can’t be given on the floors, they’re gonna be in the unit. But we can support them with high flow, noninvasive.

DM: When it comes down to it, we can support a patient in the ICU all the way down to the rehab hospital on Hi-VNI therapy.

RD: And there are even some vents on the floor. It just depends on how unstable the patient is whether in the ICU or if they can go to the floor.

JP: So again, you’re looking at that patient’s response to the therapy to determine their disposition.

DM: And not just to that therapy. It usually involves other therapies.

JP: So there’s multiple factors that drive the decision for the disposition.

DM: Yes, and the mode of therapy. Respiratory support is not usually what drives that.

RD: Yeah, because the therapists can go anywhere,it’s just really how critical your patient is.

JP: Unless the patient’s intubated.

DM: That’s exactly right. I can operate a ventilator out in the parking lot.

RD: Right. And if it’s a chronic patient that’s intubated or trached, our floor, we’ll put a vent on the floor. It really depends on how acute and how unstable that patient is. A lot of other factors.

DM: So what the trial basically showed is that and helped us to understand is don’t be afraid to try it because you can always cross over to noninvasive ventilation, that’s always an option, so don’t be afraid. Try it out. Because when you try it, you’ll see it works in most cases.

RD: I think most clinicians if they had to choose a mask vs a cannula, I would want a cannula. That’s just me.

DM: Yes, and most of the patients.

RD: Yeah, a lot of patients feel the same.

JP: You see it improving the patient outcome and the patient preference and comfort.

DM: And the patient experience, which we’re all about patient experience. Preeminence healthcare, so.

RD: Because even those hospice patients when they’re suffering, they feel so much better with that cannula. Don’t be afraid to try new technology. Don’t be afraid to change because you can always go back to the old therapy and the way you used to do things, but I think if they aren’t afraid to try it, they might see some very good patient outcomes.

JP: Outstanding discussion and thank you both very much for taking the time to share your experience with Hi-VNI Technology, specifically as an effective alternative to NIPPV. You gave us a good understanding of how you use the evidence and your clinical expertise to guide clinical decision making to manage patients in respiratory distress.